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Social Determinants of Geriatric Depression
Accepted Manuscript Title: Social Determinants of Geriatric Depression Author: Steven M. Albert PII: DOI: Reference:
S1064-7481(16)30242-1 http://dx.doi.org/doi: 10.1016/j.jagp.2016.09.002 AMGP 690
To appear in:
The American Journal of Geriatric Psychiatry
Received date: Accepted date:
15-8-2016 7-9-2016
Please cite this article as: Steven M. Albert, Social Determinants of Geriatric Depression, The American Journal of Geriatric Psychiatry (2016), http://dx.doi.org/doi: 10.1016/j.jagp.2016.09.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1 Editorial
Social Determinants of Geriatric Depression
Steven M. Albert, PhD Department of Behavioral and Community Health Sciences University of Pittsburgh
In this issue Brinda, Rajkumar, and colleagues present findings from the World Health Organization-Study on global AGEing and adult health (WHO-SAGE) to show that geriatric depression is reliably associated with poverty, economic insecurity, and national indicators of economic disparity across six low- and middle-income countries (LMICs). [1] They argue for the primacy of these factors over standard biomedical indicators. The authors examined nationally representative, cross-sectional surveys from six countries, including China (2008-10), Ghana (2008-09), India (2007-08), Mexico (2009-10), South Africa (2007-08), and Russia (2007-10), with a total of 14,877 participants over age 65. The WHO-SAGE protocol involves a symptom-based questionnaire to diagnose depression within the past 12 months and an algorithm to derive diagnoses using ICD-10. Participants were considered to meet criteria for depression if they reported two or more cardinal symptoms (“sad, empty, or depressed”; loss of interest; or low energy), plus at least one other symptom most of the day and almost every day for at least two weeks. The 12-month cross-national prevalence of geriatric depression was 4.7% (95% CI, 1.9-11.9). The confidence interval is large, in keeping with impressive variation across countries: 1.4% in China, 2.0% in South Africa, 4.4% in Russia,
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2 6.3% in Mexico, 9.7% in Ghana, and 15.0% in India. Variation was similarly large for suicidal ideation: 0.5% in China, 1.1% in South Africa, 3.1% in Mexico, 3.8% in Russia, 5.2% in Ghana, and 7.4% in India. The ratio across countries is more than 10-fold for depression (such that depression among older adults is 10.7 times higher in India than China) and nearly 15-fold for suicidal ideation. The rank order across countries for depression and suicidal ideation, on the other hand, was mostly similar. Significant correlates of depression included female gender, illiteracy, poverty, indebtedness, past informal-sector occupation, bereavement, angina, and stroke, which all increased the odds of depression, and pension support and health insurance, which lowered the odds. An index of wealth (ownership of durable assets, house dwelling characteristics, type of toilet access, and source of drinking water) was also associated with geriatric depression. Older people in the lowest wealth quintile faced a higher risk for depression in meta-analysis (pooled adjusted odds ratio, POR, 1.47; 95% CI 1.1-1.9), after adjusting for age and gender. In four of the six countries (China, India, Mexico, South Africa) geriatric depression was more concentrated among socioeconomically disadvantaged older adults. Ghana and Russia were the exceptions. If individual factors, such as hunger or lack of social insurance, as well as broad measures of economic standing are central risk factors for depression in old age, what are we to conclude? Brinda, Rajkumar, and colleagues draw two conclusions. First, “social and economic factors play an important role in the etiopathogenesis, diagnosis, management, and prevention of geriatric depression in all cultures.” Second, the key to lowering the risk of geriatric depression is not individual therapy but rather broader efforts to reduce economic disparities. They are critical of western psychiatry. By “medicalizing” psychosocial distress we have “shifted the
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3 focus from the responsibilities of the states for poverty and structural violence, and transferred pathology and burden to individuals.” In this conclusion, the authors agree with anthropological studies of mental health in lowincome countries. For example, a study of suicide in Sri Lanka claims we should “never assume that suicide is caused by depression or other deep-seated mental illness; [instead,] consider the social practices through which suicide and social and psychological problems are expressed.” [2] This approach is often considered a challenge to the Global Mental Health Movement (http://www.globalmentalhealth.org/), a WHO effort that stresses the need to address psychopathology and poor mental health to prevent suicide, though this approach does not rule out allied efforts to address social determinants and reduce health disparities. [3] The mostly consistent association between geriatric depression and poverty across disparate countries suggests a key role for social determinants in the risk for common mental disorders. Yet the conclusion should be considered in light of at least three caveats. First, it is hard to identify exactly how poverty or economic insecurity increases the risk of depression. Is it stress from economic insecurity? Here it may be useful to examine what we mean by “depression” in surveys. The survey-based measure likely captures poor morale and psychosocial distress along with clinical depression. The former may be more reliably associated with socioeconomic conditions. A design involving clinical diagnostic interviews with a random group of participants meeting WHO-SAGE criteria for depression would be helpful for clarifying the extent to which social determinants affect distress as opposed to clinically significant depression. The great variation in prevalence across countries suggests differences in the extent to which the WHO-SAGE measure captures these different components of mental health. Second, readers should take note of Figure 3 in the supplementary materials. The figure
Page 3 of 5
4 shows a wealth index gradient for prevalence of depression in only three of the six countries (China, Ghana, India). In other countries the prevalence of depression appears to be unrelated to wealth. These are unadjusted estimates but cast some doubt on the universality of the association or at least suggest the need to consider mediating or moderating factors. What factor might be relevant? Brinda, Rajkumar, and colleagues did not have strong measures of disability. The WHO-SAGE survey includes the WHODAS-II, but the authors did not choose to examine measures of activities of daily living (difficulty or need for help in bathing or dressing, for example). Yet we know from other studies, such as the Women’s Health and Aging Study (WHAS), that disability is central for mental health. [4] It would be valuable to consider disability and supports for daily function as one route by which social determinants affect the risk of geriatric depression.
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5 References 1. Brinda EM, Rajkumar AP, Attermann J, Gerdtham UG, Enemark U, Kuruthukulangara SJ. Health, social, and economic variables associated with depression among older peoplein Low and Middle Income Countries: WHO Study on global AGEing and adult health. Am J Geriatric Psychiatry 2016; this issue.
2. Widger T. Suicide in Sri Lanka: The anthropology of an epidemic. Routledge Contemporary South Asia Series, 90, 2015. 3. Albert SM, Edelstein OE, Anderson SJ, Dew MA, Reynolds CF. Global priorities and possibilities.” In Prevention of Late Life Depression: Current Clinical Challenges and Priorities. Ed. Okereke OI. Dordrecht: Human Press, 2015, Pp. 171-184. 4. Guralnik JM, Fied LP, Sionsick EM, Kasper JD, Lafferty ME. Eds. The Women’s Health and Aging Study: Health and Social Characteristics of Older Women and Disability. Bethesda, MD: National Institute of Aging, 1995. NIH Pub. No. 95-4009.
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S1064-7481(16)30242-1 http://dx.doi.org/doi: 10.1016/j.jagp.2016.09.002 AMGP 690
To appear in:
The American Journal of Geriatric Psychiatry
Received date: Accepted date:
15-8-2016 7-9-2016
Please cite this article as: Steven M. Albert, Social Determinants of Geriatric Depression, The American Journal of Geriatric Psychiatry (2016), http://dx.doi.org/doi: 10.1016/j.jagp.2016.09.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1 Editorial
Social Determinants of Geriatric Depression
Steven M. Albert, PhD Department of Behavioral and Community Health Sciences University of Pittsburgh
In this issue Brinda, Rajkumar, and colleagues present findings from the World Health Organization-Study on global AGEing and adult health (WHO-SAGE) to show that geriatric depression is reliably associated with poverty, economic insecurity, and national indicators of economic disparity across six low- and middle-income countries (LMICs). [1] They argue for the primacy of these factors over standard biomedical indicators. The authors examined nationally representative, cross-sectional surveys from six countries, including China (2008-10), Ghana (2008-09), India (2007-08), Mexico (2009-10), South Africa (2007-08), and Russia (2007-10), with a total of 14,877 participants over age 65. The WHO-SAGE protocol involves a symptom-based questionnaire to diagnose depression within the past 12 months and an algorithm to derive diagnoses using ICD-10. Participants were considered to meet criteria for depression if they reported two or more cardinal symptoms (“sad, empty, or depressed”; loss of interest; or low energy), plus at least one other symptom most of the day and almost every day for at least two weeks. The 12-month cross-national prevalence of geriatric depression was 4.7% (95% CI, 1.9-11.9). The confidence interval is large, in keeping with impressive variation across countries: 1.4% in China, 2.0% in South Africa, 4.4% in Russia,
Page 1 of 5
2 6.3% in Mexico, 9.7% in Ghana, and 15.0% in India. Variation was similarly large for suicidal ideation: 0.5% in China, 1.1% in South Africa, 3.1% in Mexico, 3.8% in Russia, 5.2% in Ghana, and 7.4% in India. The ratio across countries is more than 10-fold for depression (such that depression among older adults is 10.7 times higher in India than China) and nearly 15-fold for suicidal ideation. The rank order across countries for depression and suicidal ideation, on the other hand, was mostly similar. Significant correlates of depression included female gender, illiteracy, poverty, indebtedness, past informal-sector occupation, bereavement, angina, and stroke, which all increased the odds of depression, and pension support and health insurance, which lowered the odds. An index of wealth (ownership of durable assets, house dwelling characteristics, type of toilet access, and source of drinking water) was also associated with geriatric depression. Older people in the lowest wealth quintile faced a higher risk for depression in meta-analysis (pooled adjusted odds ratio, POR, 1.47; 95% CI 1.1-1.9), after adjusting for age and gender. In four of the six countries (China, India, Mexico, South Africa) geriatric depression was more concentrated among socioeconomically disadvantaged older adults. Ghana and Russia were the exceptions. If individual factors, such as hunger or lack of social insurance, as well as broad measures of economic standing are central risk factors for depression in old age, what are we to conclude? Brinda, Rajkumar, and colleagues draw two conclusions. First, “social and economic factors play an important role in the etiopathogenesis, diagnosis, management, and prevention of geriatric depression in all cultures.” Second, the key to lowering the risk of geriatric depression is not individual therapy but rather broader efforts to reduce economic disparities. They are critical of western psychiatry. By “medicalizing” psychosocial distress we have “shifted the
Page 2 of 5
3 focus from the responsibilities of the states for poverty and structural violence, and transferred pathology and burden to individuals.” In this conclusion, the authors agree with anthropological studies of mental health in lowincome countries. For example, a study of suicide in Sri Lanka claims we should “never assume that suicide is caused by depression or other deep-seated mental illness; [instead,] consider the social practices through which suicide and social and psychological problems are expressed.” [2] This approach is often considered a challenge to the Global Mental Health Movement (http://www.globalmentalhealth.org/), a WHO effort that stresses the need to address psychopathology and poor mental health to prevent suicide, though this approach does not rule out allied efforts to address social determinants and reduce health disparities. [3] The mostly consistent association between geriatric depression and poverty across disparate countries suggests a key role for social determinants in the risk for common mental disorders. Yet the conclusion should be considered in light of at least three caveats. First, it is hard to identify exactly how poverty or economic insecurity increases the risk of depression. Is it stress from economic insecurity? Here it may be useful to examine what we mean by “depression” in surveys. The survey-based measure likely captures poor morale and psychosocial distress along with clinical depression. The former may be more reliably associated with socioeconomic conditions. A design involving clinical diagnostic interviews with a random group of participants meeting WHO-SAGE criteria for depression would be helpful for clarifying the extent to which social determinants affect distress as opposed to clinically significant depression. The great variation in prevalence across countries suggests differences in the extent to which the WHO-SAGE measure captures these different components of mental health. Second, readers should take note of Figure 3 in the supplementary materials. The figure
Page 3 of 5
4 shows a wealth index gradient for prevalence of depression in only three of the six countries (China, Ghana, India). In other countries the prevalence of depression appears to be unrelated to wealth. These are unadjusted estimates but cast some doubt on the universality of the association or at least suggest the need to consider mediating or moderating factors. What factor might be relevant? Brinda, Rajkumar, and colleagues did not have strong measures of disability. The WHO-SAGE survey includes the WHODAS-II, but the authors did not choose to examine measures of activities of daily living (difficulty or need for help in bathing or dressing, for example). Yet we know from other studies, such as the Women’s Health and Aging Study (WHAS), that disability is central for mental health. [4] It would be valuable to consider disability and supports for daily function as one route by which social determinants affect the risk of geriatric depression.
Page 4 of 5
5 References 1. Brinda EM, Rajkumar AP, Attermann J, Gerdtham UG, Enemark U, Kuruthukulangara SJ. Health, social, and economic variables associated with depression among older peoplein Low and Middle Income Countries: WHO Study on global AGEing and adult health. Am J Geriatric Psychiatry 2016; this issue.
2. Widger T. Suicide in Sri Lanka: The anthropology of an epidemic. Routledge Contemporary South Asia Series, 90, 2015. 3. Albert SM, Edelstein OE, Anderson SJ, Dew MA, Reynolds CF. Global priorities and possibilities.” In Prevention of Late Life Depression: Current Clinical Challenges and Priorities. Ed. Okereke OI. Dordrecht: Human Press, 2015, Pp. 171-184. 4. Guralnik JM, Fied LP, Sionsick EM, Kasper JD, Lafferty ME. Eds. The Women’s Health and Aging Study: Health and Social Characteristics of Older Women and Disability. Bethesda, MD: National Institute of Aging, 1995. NIH Pub. No. 95-4009.
Page 5 of 5